Peritonsillar Abscess and Antibiotic Prescribing for Respiratory Infection in Primary Care: A Population-Based Cohort Study and Decision-Analytic Model.

PURPOSE: To quantify the risk of peritonsillar abscess (PTA) following consultation for respiratory tract infection (RTI) in primary care. METHOD: A cohort study was conducted in the UK Clinical Practice Research Datalink including 718 general practices with 65,681,293 patient years of follow-up and 11,007 patients with a first episode of PTA. From a decision tree, Bayes theorem was employed to estimate both the probability of PTA following an RTI consultation if antibiotics were prescribed or not, and the number of patients needed to be treated with antibiotics to prevent 1 PTA. RESULTS: There were 11,007 patients with PTA with age-standardized incidence of new episodes of PTA of 17.2 per 100,000 patient years for men and 16.1 for women; 6,996 (64%) consulted their practitioner in the 30 days preceding PTA diagnosis, including 4,243 (39%) consulting for RTI. The probability of PTA following an RTI consultation was greatest in men aged 15 to 24 years with 1 PTA in 565 (95% uncertainty interval 527 to 605) RTI consultations without antibiotics prescribed but 1 in 1,139 consultations (1,044 to 1,242) if antibiotics were prescribed. One PTA might be avoided for every 1,121 (975 to 1,310) additional antibiotic prescriptions for men aged 15 to 24 years and 926 (814 to 1,063) for men aged 25 to 34 years. The risk of PTA following RTI consultation was smaller and the number needed to treat higher at other ages and risks were lower in women than men. CONCLUSIONS: The risk of PTA may be lower if antibiotics are prescribed for RTI but even in young men nearly 1,000 antibiotic prescriptions may be required to prevent 1 PTA case. We caution that lack of randomization and data standardization may bias estimates.

[The specific features of the past medical history and etiology of pharyngeal abscess in the children]. / Osobennosti anamneza i étiologii abstsessov glotki u detei.

The present study was undertaken for the purpose of elucidating the specific features of the past medical history and the etiological factors responsible for the development of tonsillogenic pharyngeal abscesses in the children. We performed the retrospective analysis of the medical histories of 291 children presenting with this condition who had been admitted for the treatment to the ENT Department of the Morozovskzya City Children's Clinical Hospital during the period from January till December 2015. The study has demonstrated the following most common shortcomings of the outpatient treatment of the patients suffering from chronic tonsillitis at the stage preceding formation of paratonsillar abscess: inadequate antibacterial therapy of acute chronic tonsillitis or its exacerbation and limited indications for tonsillectomy at the level of the outpatient treatment. The leading role in the etiology of tonsillogenic pharyngeal abscesses in the children is played by beta-hemolytic Streptococcus of group A. It is concluded that the medical history suggesting past paratonsillar abscess is the absolute indication for the subsequent tonsillectomy in the children of any age.

Metronidazole in conjunction with penicillin neither prevents recurrence nor enhances recovery from peritonsillar abscess when compared with penicillin alone: a prospective, double-blind, randomized, placebo-controlled trial.

OBJECTIVES: The objectives of this study were to evaluate the efficacy of metronidazole in conjunction with penicillin in preventing the recurrence of peritonsillar abscess (PTA) and to learn whether metronidazole enhances the recovery from PTA when compared with penicillin alone. METHODS: In this prospective, double-blind, randomized, placebo-controlled trial, 200 adult outpatients with PTA at our ear, nose and throat emergency department received either penicillin (1 000 000IU) × 3 and metronidazole (400 mg) × 3 for 10 and 7 days orally (combination group, N = 100) or penicillin and placebo (penicillin group, N = 100) after incision and drainage of the PTA. Afterwards they received a symptom questionnaire via e-mail daily for 2 weeks, then weekly for 6 weeks. The primary outcome was efficacy of metronidazole in conjunction with penicillin in preventing PTA recurrence in 56 days; the secondary outcome was ability of metronidazole plus penicillin to enhance recovery from PTA in 28 days. All healthcare contacts were registered during follow-up. Registered on www.clinicaltrials.gov with the identifier NCT01255670. RESULTS: Of the 200 patients, 20 returned to hospital with recurrent symptoms, 10 in each group (P = 1.00). In the combination group, the mean (SD) duration of throat-related symptoms was 5.6 (5.0) days and in the penicillin group it was 5.3 (2.7) days, values for fever were 1.5 (0.9) and 1.6 (1.0) days, respectively, and those for poor overall physical condition were 4.0 (3.9) and 4.5 (4.9) days; there were no significant differences between groups. The adverse effects nausea and diarrhoea lasted longer in the combination group (P = 0.01). CONCLUSIONS: For healthy adult PTA patients treated with incision and drainage, metronidazole neither prevents recurrence nor enhances recovery when combined with penicillin compared with penicillin alone, but instead leads to increased adverse effects.

A cost-effectiveness analysis of identifying Fusobacterium necrophorum in throat swabs followed by antibiotic treatment to reduce the incidence of Lemierre's syndrome and peritonsillar abscesses.

The main purpose of this paper was to estimate the cost per quality-adjusted life year (QALY) saved by identifying Fusobacterium necrophorum in throat swabs followed by proper antibiotic treatment, to reduce the incidence of Lemierre's syndrome and peritonsillar abscesses (PTA) originating from a pharyngitis. The second purpose was to estimate the population size required to indicate that antibiotic treatment has an effect. Data from publications and our laboratory were collected. Monte Carlo simulation and one-way sensitivity analysis were used to analyse cost-effectiveness. The cost-effectiveness analysis shows that examining throat swabs from 15- to 24-year-olds for F. necrophorum followed by antibiotic treatment will probably be less costly than most other life-saving medical interventions, with a median cost of US$8,795 per QALY saved. To indicate a reduced incidence of Lemierre's syndrome and PTA in Denmark, the intervention probably has to be followed for up to 5 years. Identifying F. necrophorum in throat swabs from 15- to 24-year-olds followed by proper antibiotic treatment only requires a reduction of 20-25 % in the incidence of Lemierre's syndrome and PTA to be cost-effective. This study warrants further examination of the effect of antibiotic treatment on the outcome of F. necrophorum acute and recurrent pharyngitis, as well as the effect on Lemierre's syndrome and PTA.

Flemón periamigdalar / Peritonsillar phlegmon

Las infecciones de las vías altas en la infancia tienen una elevada incidencia y son fuente habitual de consultas, cuyo manejo a veces es controvertido por la excesiva utilización de medicación. El anillo de Waldeyer actúa como un paraguas protector, al impedir muchas veces el progreso de las infecciones al resto del organismo. En ocasiones, por circunstancias poco conocidas, esa protección puede perderse y causar una patología relevante para la salud del niño. Presentamos el caso de una niña con un proceso realmente poco frecuente en la infancia, que es preciso diagnosticar con prontitud para evitar su progreso. El flemón periamigdalar es el primer síntoma de un absceso y, a pesar de que la primera intención terapéutica es el ingreso de los pacientes, administrar tratamiento intravenoso y realizar exámenes complementarios complejos, en bastantes casos podría adoptarse una actitud más conservadora, que fue la que se siguió en esta paciente. Se revisa la bibliografía para conocer los últimos cambios en la actuación ante esta patología (AU)

The upper respiratory airways infections in childhood have a high incidence and they are a frequent source of consultation whose management sometimes is controversial because of the use of excessive treatment. The Waldeyer's tonsillar ring is the umbrella protector to prevent many times the infection’s progress to the whole organism. Sometimes due to less known circumstances this protection can be lost and therefore cause an important pathology in the health of the child. We show a girl with a very infrequent process during childhood and which is necessary to diagnose rapidly to avoid its progress. The peritonsilar phlegmon is the first step for an abscess and even though the first intention is to hospitalize hospital, intravenous treatment, complex complementary exams, in many cases a more conservative attitude could be adopted than the one we used in this case. We review the bibliography to learn the last changes in how to act in the presence of this disease (AU)

[Prior use of anti-inflammatory and antibiotic drugs in patients hospitalized for peritonsillar abscess]. / Analyse de l'exposition préalable aux anti-inflammatoires et aux antibiotiques d'une cohorte de 34 patients hospitalisés au CHU de Nantes pour phlegmon périamygdalien.

OBJECTIVE: The purpose of this study was to describe the characteristics of patients hospitalized for a peritonsillar abscess over a 1-year period and to evaluate the proportion of patients exposed to anti-inflammatory and antibiotic drugs before hospitalization. DESIGN: Adult patients hospitalized in the ENT department at the Nantes University Hospital were included in the study during 2006. Data related to prior use of anti-inflammatory and antibiotic drugs, microbiology and treatment was analyzed. RESULTS: Thirty-four patients were included in the study, 20 (59%) and 21 (62%) patients had been previously exposed to anti-inflammatory and antibiotic drugs, respectively. Half of the patients had received antibiotics despite the negativity of the rapid screening test. All diagnoses were made on pus examination after aspiration. Tonsillectomy was performed only in two cases. A total of 21 bacterial isolates (13 anaerobic and 9 aerobic) were identified. Single bacterial isolates were recovered in 8 infections. The most frequent bacteria were Streptococcus, Fusobacterium, and Prevotella. CONCLUSIONS: Many patients were exposed to both anti-inflammatory and antibiotic drugs, which did not prevent the peritonsillar abscess.

Use of antibiotics for sore throat and incidence of quinsy.

BACKGROUND: Quinsy is the most common major suppurative complication of sore throat. Evidence on the effectiveness of antibiotics in preventing quinsy is sparse. AIM: To assess the incidence of quinsy and the pattern of presentation, and to identify variables that predict the development of quinsy. DESIGN OF STUDY: Case-control study. SETTING: UK-wide primary care. METHOD: Retrospective analysis of data from the General Practice Research Database (GPRD) for the years 1995-1997. RESULTS: There were 606 recorded cases of patients with quinsy, but only 192 (31%) of these patients presented following an initially uncomplicated sore throat. Patients with quinsy were more likely to be aged 21-40 years (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.7 to 3.6, compared with other ages), smokers (OR = 2.5, 95% CI = 1.8 to 3.5), and male (OR = 1.6, 95% CI = 1.1 to 2.2). Quinsy developed very quickly for most patients (median of 2 days after tonsillitis and 3 days after a sore throat). For cases initially labelled as tonsillitis, there was a nonsignificant trend of antibiotics preventing quinsy (OR = 0.6, 95% CI = 0.3 to 1.3), but no evidence that antibiotics prevent quinsy for cases labelled as sore throat or pharyngitis (OR = 1.2, 95% CI = 0.7 to 2.2). CONCLUSION: Most patients with quinsy develop the condition rapidly, and many do not present with a respiratory tract infection to their GP first. The current low doses of antibiotics used in modern community settings may be less likely to protect against quinsy than the trial evidence suggests.

[Trends and complications in the management of peritonsillar abscess with emphasis on children]. / Peritonsillarabszess Trends und Komplikationen bei der Behandlung, insbesondere bei Kindern.

BACKGROUND: Peritonsillar abscess (PTA) is the most common deep neck space infection treated by otolaryngologists affecting predominantly young adults. Children present a challenge owing to the difficulty in obtaining an exact history and adequate physical examination. Particularly for the pediatric age group controversy surrounds the question of optimal treatment. This study was undertaken to evaluate bleeding complications following immediate tonsillectomy (TAC) in a pediatric population (<16 years) of age and to compare our management protocol with the current status in the literature. MATERIAL AND METHODS: The data of 218 children who had undergone TAC between January 1988 and January 2003 in our clinic were enrolled in a retrospective study. The youngest patient was 18 months, the oldest 15.9 years of age (mean: 14.53; median: 14; STD: 12.11 years). 95 patients were male (43.6%), 123 female (56.4%). Various treatment protocols of the current literature are addressed. RESULTS: Postoperative hemorrhage (all from the opposite side) requiring surgical treatment under general anesthesia occurred in 4 children (1.8%). Repeated hemorrhage did not occur, blood transfusions were not required, there was no case with lethal outcome. Several reports indicate that needle aspiration (NP) or incision and drainage (ID) may suffice for the majority of cases but do not distinguish between different treatments for children and adults. More recently, conscious sedation has become a great support for pediatric treatment protocols. CONCLUSIONS: The initial success rates of NP or ID are both very high (>90%) and the overall recurrence rate is low, particularly in children. Only for selected subgroups, patients may profit from TAC, which was clearly not associated with an increased risk of bleeding in our pediatric population.

[Does antibiotic therapy hinder the course of peritonsillar abscesses?]. / Verhindert eine antibiotische Therapie die Entstehung von Peritonsillarabszessen?

INTRODUCTION: Peritonsillar abscess (quinsy) is a complication of acute bacterial tonsillitis. In a prospective study, the influence of antibiotic therapy on the clinical course in patients with quinsy was analysed. METHOD: History and clinical signs in patients with quinsy referred to our hospital were assessed by a structured questionnaire. Pus was cultured under aerobic and anaerobic conditions. RESULTS: 40 patients were enrolled in the study, 18 of whom (45%) were treated with antibiotics prior to admission. There was no significant difference in history and clinical signs between the patients with antibiotics and the group without. The microbiological results showed a dominant role of anaerobic bacteria without significant difference between the two groups of patients. DISCUSSION: Antibiotic therapy did not prevent the occurrence of peritonsillar abscess in 45% of our patients and had no influence on the clinical course of the disease. A possible reason for these findings is that the onset of antibiotic therapy was too late in the disease process, or, in some cases, that an antibiotic drug with an inadequate antimicrobiological spectrum was chosen.

[Present-day aspects of tonsillar problems]. / Nekotorye aspekty tonzilliarnoi problemy v nastoiashchee vremia.

The analysis of 1247 case histories of chronic tonsillitis and peritonsillar abscesses of tonsillogenic origin has shown that annual number of tonsillectomies for chronic tonsillitis is decreasing while the number of patients with peritonsillar abscesses is going up. The tendency is explained by several factors, among them overestimation of the efficacy reached with conservative therapy of chronic tonsillitis. The authors promote wider use of tonsillectomy as an effective preventive tool for peritonsillar abscesses. The latter should be more frequently managed with abscess tonsillectomy.

What a difference a day makes: a decision analysis of adult streptococcal pharyngitis.

With the availability of group A beta-hemolytic streptococcal (GABHS) antigen detection tests, the management of adult pharyngitis is being reassessed. A decision analytic model was developed which considered four strategies: immediate treatment, no treatment, performing a rapid antigen test, or obtaining a bacterial culture. Patient outcomes were expressed in "well" days, which were reduced by the "sick" days associated with adverse reactions to treatment or complications of GABHS infection. When immediate test results are available, testing is the optimal strategy for probabilities of GABHS between 1 and 49 per cent. This range includes almost all patients, using probability estimates based on clinical criteria. The absolute benefit of testing was 0.1 days. The major advantage of a rapid test is the avoidance of penicillin reactions. Variations in the symptomatic benefits of treatment had minimal effects on the analysis. The analysis supports the use of an antigen test for adult patients with pharyngitis.

Throat culture in impending peritonsillar abscess.

Throat cultures done immediately before the development of a peritonsillar abscess were positive for beta-hemolytic streptococci in only one of 12 cases. To prevent suppurative complications such as peritonsillar abscess, treatment with antibiotics may be indicated in selected severe cases of tonsillar infections despite negative throat cultures.